APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE (Claims Made and Reported Policy) Administered by Alta Pro Insurance Services 14141 Farmington Rd., Livonia, MI 48154 Phone: (866)532-2582 Fax: (734)786-0067 Email: Apps@altaproinsurance.com THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED INSURANCE POLICY. IT IS IMPORTANT THAT YOU REPORT ANY KNOWN FACTS OR CIRCUMSTANCES THAT COULD REASONABLY BE EXPECTED TO RESULT IN A CLAIM TO YOUR CURRENT INSURER OR PURCHASE AN EXTENDED REPORTING PERIOD ENDORSEMENT IN ORDER TO PRESERVE COVERAGE FOR SUCH INCIDENTS. Full Name of Applicant Firm: Contact: Address 1: Address 2: City: State: Zip Code: County: Phone: Fax: E-mail: No. Lawyers in Firm: No. Support Staff: Do you have other office locations? Yes No If yes, how many? 1. Requested Effective Date: Date Firm Established: 2. a. Current Limits: b. Limits desired this year: c. Current Deductible: d. Deductibles desired this year: e. Optional coverages you are requesting: Please provide a list showing each location and the number of attorneys at each location First Dollar Defense: Aggregate Deductible: Claim Expense Outside Limits: f. Retroactive Date Requested: 3. a. Is the firm currently insured for professional liability? Yes No Please provide a copy of your current policy declarations including retroactive date as evidence of current coverage. b. Does your current policy have any type of endorsements that exclude or modify coverage? Yes No If yes, please provide a copy of each such endorsement. 4. List the names of all predecessor firms of the applicant firm. Name only those firms where the applicant is a majority successor to the predecessor firm s assets and liabilities. Name of Predecessor Firm Date Established Number of Lawyers 5. a. In the last 12 months, how many attorneys have left your firm? b. Joined the firm? c. How many attorneys does the firm plan to add during the next 12 months? d. In the last 12 months, how many non lawyer employees have left your firm? 6. Has any professional liability insurance for the applicant, or any member of the applicant firm ever been declined or cancelled, refused to be renewed or accepted only on special terms? If yes, please provide a detailed narrative in the space provided on page 2 or on firm letterhead. 7. Please identify your legal professional liability insurance for the past five years. Company Policy Period Limits Deductible Premium # of Attorneys Yes No 8. Does any client or group of related clients make up 10% or more of the firm s gross receipts? Yes No If yes, please list all clients and the percentage of the firm s gross receipts in the space provided below. 9. Does your firm use any attorneys not listed on this application to provide legal services for the firm? Yes No If yes, list all such lawyers in the space provided below and describe their relationship to the firm. 10. a) Does your firm share cases with other attorneys or law firms? Yes No AP APP LPL-01 (06/15) Page 1 of 7
b) Does your firm share letterhead with other attorneys or law firms? Yes No c) Does your firm refer clients to other firms and retain a fee? Yes No If "yes", please attach a list all such lawyers or firms, percentage of your practice, and a description of the cases. Please provide proof of insurance for all such lawyers. 11. In the last five years, has any lawyer listed on the application been an officer, director, shareholder, Yes No member, employee, or exercised fiduciary control over an entity other than the applicant firm? If yes, a complete Outside Interest Supplement must be provided. 12. Is any lawyer listed on the application an employee of an entity other than the applicant firm? Yes No If yes, please explain in the space provided below or on firm letterhead. 13. Has any member of the firm provided legal services involving publicly traded securities or securities Yes No that are not exempt from registration? If yes, please explain in the space provided below or on firm letterhead. 14. Has any member of the firm been involved in class action or mass tort litigation? Yes No If yes, please explain in the space provided below or on firm letterhead. 15. Does any member of the firm provide services to, or sit on the board of directors of, Yes No a financial institution? If yes, a complete Financial Institution Supplement must be provided. 16. Is any firm member aware of any incident, facts, circumstances, acts or omissions that could Yes No result in a professional liability claim against the firm or predecessor firm or against any current or former firm member while affiliated with the firm or predecessor firm? If yes, a complete Claim Supplement form must be provided for each incident. 17. Has any member of the firm been the subject of any reprimand or disciplinary action or Yes No refused admission to the bar or any bar association, court or administrative agency? If yes, explain in detail in the space provided below. 18. a. In the last 10 years, has any professional liability claim been made or suit brought against Yes No the firm or predecessor firm or any member of the firm or predecessor firm? If yes, how many claims: b. Has any member of the firm ever had a claim? Yes No If yes, a complete Claim Supplement form must be provided for each claim or suit within the past 10 years. SPACE PROVIDED FOR ADDITIONAL INFORMATION AP APP LPL-01 (06/15) Page 2 of 7
19. Complete the following table based upon either your gross revenue or billable hours for each category. The total must equal 100% This Practice Profile is based on gross revenue or billable hours. PRACTICE PROFILE Area of Practice Percentage Area of Practice Percentage Admiralty (AM) Plaintiff %: Health Care (HC) Plaintiff %: Defense %: Defense %: Antitrust (AT) Plaintiff %: Insurance Defense (ID) Coverage%: Defense %: Defense %: Appellate (AP) Plaintiff %: Intellectual Property * (IP) Patent %: Defense %: Trademark %: Other %: Litigation%: Arbitration, Mediation (ADR) %: Labor & Employment (LE) Management %: Bankruptcy * (BC) Debtor%: Union/Labor%: Trustee%: Other %: Business Formation & Form/Alt %: Municipal Law (ML) Defense %: Alteration, Merger/Acquisition * Merge/Ac%: Financial Advice: (CF) Business Transactions - Public Corp %: Natural Resources, Oil & Gas (NR) Plaintiff %: Corporate & Commercial * (CF) Private %: Defense %: Civil Rights/Discrimination (CR) Plaintiff %: Personal Injury Legal Malpractice* Plaintiff %: Defense %: (PI) Defense %: Collections * (CB) Creditor %: Personal Injury Medical Plaintiff %: Debtor %: Malpractice* (PI) Defense %: Commercial Litigation (GL) Plaintiff %: Other %: Defense %: Personal Injury Mass Tort, Plaintiff %: Other %: Class Action * (PI) Defense %: Construction Law (CL) Plaintiff %: Other %: Defense%: Personal Injury Products Liability* Plaintiff %: Transaction %: (PI) Defense %: Criminal Defense (CD) %: Other %: Employee Benefits (EB) %: Personal Injury * (PI) Plaintiff%: Entertainment/Agency/ Management %: Defense %: /Sports Agency *(EN) Environmental * (ER) Plaintiff %: Real Estate * (RE) Commercial %: Defense %: Residential%: Other %: Securities * (SE) Public Offering%: Estate, Probate, Trust * (ES) (1) Est. Planning %: Corp. Bonds %: Trust Admin. %: Private Placemt: Family Law (FL) (2) Adoption %: Tax, Tax Opinions (TX) Personal %: Divorce %: Corporate %: Financial Institutions * (FI) %: Workers Compensation/Social Plaintiff %: General Civil Litigation (GL) Plaintiff %: Security (WC) Defense %: Defense %: Other %: Other %: Other (OT) (Describe): %: Immigration (IM) %: %: * Indicates that completion of the corresponding Supplement is required. (1) Estate/Trust/Probate. In the last 24 months, please indicate the following: Average asset value of estates handled: Highest asset value of estates handled: Is any firm member a trustee of any client estate? Yes No If yes, please complete an Outside Interest Supplement (2) Family Law. In the last 24 months, please indicate the following: Average value of property settlement handled: Does any firm member provide any of the following services? Highest value of property settlement handled: Surrogacy contracts Ovum or sperm donation contracts Embryo donation agreements AP APP LPL-01 (06/15) Page 3 of 7
20. a. Please complete the Firm Profile below for each attorney associated with your firm. Please attach an additional sheet if more space is needed. FIRM PROFILE Position Ave. Primary - P Attorney Name P, A, OC, I Hire Date Date First Admitted States Admitted Hours/ Week Secondary - S Areas of Practice Cover for work prior to date of hire by firm? Y/N P = Partner/Owner/Member A = Associate/Employee OC = Of Counsel I = Independent Contractor 21. If you are a sole practitioner, who handles your cases in the event of your incapacitation or vacation? (Please Note: If a policy is issued in reliance upon this application, it shall not apply to the attorney noted below): Name of backup attorney: 22. Total firm revenues last fiscal year: Current fiscal year revenues: 23. Does your firm accept any form of compensation other than legal fees? Yes No If yes, please provide an explanation in the space provided on page 2 or on firm letterhead. 24. Does your firm have a system for detecting and avoiding conflicts of interest? If yes, check all that apply: Index Computer Conflict Committee Oral/Memory Other: Describe: 25. a. Does or has any member of the firm engaged in a business venture with a client? Yes No b. Does or has any firm member introduced clients to one another for investment purposes? Yes No c. Does the firm ever represent adverse but friendly parties in the same matter? Yes No If yes to 25. a, b, or c, please provide an explanation in the space provided on page 2 or on firm letterhead. 26. Please indicate which of the following the firm uses to manage its docket and scheduling demands: Computer Docket Clerk/Administrator Individual Diaries Daily or Weekly firm-wide circulation of master calendar Other: Describe: 27. If the firm uses a computerized system to manage its docket and scheduling demands, please indicate below which of the following describes that system: Name of software: Updated daily Centralized/Firm-wide All branch offices integrated Monitored by multiple individuals Tracks statutes of limitations Data backed up/stored offsite Other: Describe: AP APP LPL-01 (06/15) Page 4 of 7 Yes No
28. Does the firm routinely use: Engagement letters/fee Agreements: Yes No Declination of Representation Letters: Yes No Termination of Services Letters: Yes No Regular File Status Updates: Yes No 29. Have any suits for fees been filed against clients in the last five years? Yes No If yes, please complete the Fee Suits Supplement. 30. Describe the firm s risk management activities: a. Does the firm have a formal procedures manual? Yes No b. Are all employees trained regarding firm policies and procedures? Yes No c. Are new attorneys supervised by a more senior attorney? Yes No d. Are all cases brought in by new attorneys from prior firms reviewed by at least one senior partner or officer of the firm for potential conflicts of interest? Yes No d. Is support personnel work reviewed by an attorney prior to release to the client? Yes No e. Are all new matters reviewed prior to acceptance by firm management? Yes No f. Does firm management regularly review all ongoing matters? Yes No GENERAL FRAUD NOTICE Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime in certain jurisdictions. NOTICE TO INDIANA APPLICANTS A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. NOTICE TO KENTUCKY APPLICANTS Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. NOTICE TO MINNESOTA AND OHIO APPLICANTS Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application, or files a claim containing a false or deceptive statement, is guilty of insurance fraud. NOTICE TO TENNESSEE APPLICANTS It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. AP APP LPL-01 (06/15) Page 5 of 7
APPLICANT S AUTHORIZATION AND CERTIFICATION The undersigned is an authorized representative of the prospective Named Insured, and acknowledges that the information provided with the application, including all supplements, attachments and replies to underwriter inquiries, and applications from other insurance companies which have been submitted to the Company and made a part of this application: 1. Will be relied upon by the Company in determining the acceptability of the Applicant and the premium amount to be charged; 2. Are true, accurate and complete; and 3. Will be incorporated into the policy, if issued. The applicant firm and all members of the firm understand that this is an application for insurance, and shall not bind the Company to the issuance of insurance, nor shall it bind the firm to the acceptance of a policy. THE UNDERSIGNED ON BEHALF OF THE APPLICANT FIRM AND ALL MEMBERS OF THE FIRM CERTIFIES THAT THE ABOVE APPLICATION HAS BEEN READ AND THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE TRUE, MATERIAL AND COMPLETE. THE UNDERSIGNED UNDERSTANDS THAT: (1) IF THE POLICY IS ISSUED, THIS IS DONE BY THE COMPANY IN RELIANCE UPON THESE REPRESENTATIONS; AND (2) ANY COVERAGE OBTAINED BY FRAUD, MATERIAL MISREPRESENTATION OR OMISSION IS VOID. The following number of Supplemental Claim forms are enclosed with this application: Signature of Officer or Partner of Firm Title Date AGENCY: Print Name ADDRESS: PHONE: FAX: AP APP LPL-01 (06/15) Page 6 of 7
CLAIM SUPPLEMENT 1. Full name of Applicant Firm: 2. Full name(s) of firm member(s) involved in claim: 3. Other defendants: 4. Name of potential/actual claimant(s): 5. Check whether: Incident Claim Lawsuit Disciplinary Action 6. a. Date of alleged act, error, or omission: b. Date reported to insurer: c. Name of insurance carrier responding to this claim: 7. Present status of claim (check one and include any deductible amount in figures provided): Closed Open Total loss paid (including deductible): $ Claimant's settlement demand: $ Total expense paid (including deductible): $ Defendant's offer for settlement: $ Court judgment Insurer's claim reserve: $ Out-of-court settlement Expense reserve: $ Dismissed Expenses paid to date: $ Arbitration award Currently In Suit Incident/Report Only (No reserve established, no expenses to date) 8. a. Alleged act or omission upon which claim or incident is based: b. Description of events leading to claim or incident: c. Current status: d. What steps have been taken to prevent a similar loss in the future? e. Does this claim or incident arise from an action to collect fees? Yes No I represent that the statements above are true and complete to the best of my knowledge, that I have not suppressed or misstated any facts and I understand that this supplement becomes part of my application. Signature of Officer or Partner of Firm Title Date Print Name of Officer or Partner AP APP LPL-01 (06/15) Page 7 of 7